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Transitioning to Robotic Cystectomy in Muscle-Invasive Bladder Cancer

By Caroline Seymour
Preliminary findings from an ongoing study have demonstrated efficacy and quality-of-life benefits associated with robotic-assisted cystectomy in patients with muscle-invasive bladder cancer, pointing to a potential shift in current practice.

The ongoing randomized phase III RAZOR trial is comparing open radical cystectomy (ORC) with robotic-assisted radial cystectomy (RARC) in patients with stage T1-T4, N0-N1, M0 bladder cancer. The study has a noninferiority endpoint, as well as blood transfusion rate, estimated blood loss, length of stay, complications, lymph node yield, and margin status.

Results presented at the 2017 American Urological Association (AUA) Annual Meeting showed that, of the 150 patients in the RARC arm and 156 patients in the ORC arm, estimated blood loss was substantially lower in the robotic arm. Shorter length of hospital stay was also reported for patients who underwent RARC. Complications were reported to be similar in both groups, as well as the number of lymph nodes removed.

A mainstay in clinical practice has been open cystectomy in the management of muscle-invasive bladder cancer. Respective clinical trials are few and far between, and those that have been conducted have failed to randomize all aspects of the trial, explained William C. Huang, MD. Minimally invasive approaches, such as robotic-assisted surgery, have typically been used in cancers outside of the bladder cancer realm.

In an interview during the 2018 OncLive® State of the Science SummitTM on Genitourinary Cancers, Huang, associate professor, Department of Urology, co-director, Robotics Program, Chief Urology Service, Tisch Hospital, NYU Langone Health, discussed the transition from open cystectomy to minimally invasive robotic-assisted surgery in the management of muscle-invasive bladder cancer.

How has the use of robotic surgery evolved in the treatment of patients with bladder cancer? 

A lot of the application of robotic techniques in bladder surgery essentially evolved from the use of robotic surgery in prostate surgery. For instance, the lymphadenectomy was already being done for prostate cancer and we just extended that by using robotics [in bladder cancer]. Since the removal of the bladder requires removal of the prostate as well, for many experienced prostate surgeons, removing the bladder at the same time was just an extension of a technique that we were already familiar with, so it seemed like a natural evolution for robotic surgeons to move from robotic prostate surgery to robotic bladder surgery. 

Are there new trials looking at new surgical techniques or neoadjuvant approaches?  

For bladder cancer surgery specifically, there was one randomized trial that compared robotic cystectomy to open cystectomy. In a letter to the editor we wrote, Marc A. Bjurlin, DO, of NYU Langone Health, and I pointed out that even though they presented a randomized trial, the urinary diversions in the trial were all done in an open fashion. There is, however, an ongoing trial called the RAZOR trial, which is hoping to answer some of those questions.

Is there a certain patient population that is eligible for robotic surgery? 

These are patients who are going to require removal of their bladder for the management of muscle-invasive bladder cancer. In terms of selection criteria, almost any patient who is eligible for an open cystectomy is also a candidate for the robotic approach. Exceptions would be patients who have had a large number of previous surgeries before, or patients who have a contraindication for undergoing general anesthesia and/or inflating their abdomen with air. [Additional exceptions are] patients who are morbidly obese who cannot tolerate the positioning that we use, or those who have significant pulmonary issues.

How do you see the role of surgery evolving for patients with bladder cancer? 

The gold standard treatment for patients with muscle-invasive bladder cancer remains removal of the bladder, and that necessarily won't change with the use of robotics. What will happen as time goes on is more and more people will likely utilize the robotic approach because they are much more comfortable doing robotic surgery for other urologic cancers. I do see that there is going to be a greater uptick in the use of robotic-assisted bladder removals, or robotic cystectomies as time goes on. 

What general advice would you like to provide community physicians with on how this field is changing?

One of the things that has to be taken into consideration is the removal of the bladder itself. Whether it is done through an open incision or a robotic incision is not the main source of morbidity or complications from this type of surgery; it’s really the reconstruction that’s done afterwards.

The majority of robotic cystectomies these days are still done with an eventual conversion to an open urinary reconstruction. That is the great barrier to a widespread adoption of the robotic-assisted removal of the bladder. Unless we see a benefit in the reconstruction, I don't think a lot of people will necessarily make that jump to performing the urinary reconstruction robotically. If they're going to perform the open reconstruction anyway, they may ask themselves, “What is the point of doing the first part robotically if I'm going to convert to an open procedure for the second half of the operation?”

Parekh, Dipen. PNFLBA-18. A prospective, multicenter, randomized trial of open versus robotic radical cystectomy (RAZOR). J of Urol. 2017;197(4S):e918. doi: 10.1016/j.juro.2017.03.044.

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